foster care outcomes: does foster care help or harm children’s emotional and social development?...

Foster Care Outcomes:Does Foster Care Help or Harm

Children’s Emotional and Social Development?

Dee WilsonPresentation to CA Medical Consultants

March 17, 2008

2

Many foster care placements last for brief periods

of time; median length of stay (LOS) for CPS

placements in Washington State is about 1 year.

However, approximately one quarter of children in

out-of-home care for at least 60 days in

Washington State are still in care 3 years after

their date of placement.

3

Surveys of foster children around the world almost

always elicit highly favorable views of foster care.

“We are apparently in the presence of a robust

phenomenon that does not appear to be either

sample specific or country specific.”

(Flynn, Robitaille, & Ghazal, 2006)

4

The odds of a child being reunified with

birth parents decline dramatically as

length of stay (LOS) increases.

5

Children with behavioral problems have

much lower reunification rates than

children without behavior problems.

(Landsverk, et al, 1996)

6

One-half to two-thirds of children in

out-of-home care have serious mental

health problems; only 25% of children

with MH problems receive MH

treatment.

Source: National Survey of Child and Adolescent Well-Being

7

Long LOS are associated with multiple

placements.

Almost half of children in care for 4 or

more years in Washington State have

had 5 or more placements.

8

Placement disruptions are not the same as

placement moves.

Some of the best recent research has classified

children as achieving “early stability,” “late

stability,” “variable stability,” or “unstable”

instead of counting placement events.

(Rubin, et al, 2007)

9

In one recently published Australian

study, 20% of foster youth were found

to be “homeless in care”.

Barber & Delfabbro (2006) refer to the

“truly wretched conditions under which

these foster children live.”

10

Both Rubin, et al (USA, 2007) and Barber &

Delfabbro (Australia, 2006) found that

approximately 20% of children in foster care

were “unstable” in care at 18 months to 2 years

after date of placement. Rubin, et al found that

almost one-third of children 10 and older were

still unstable in care at 18 months after original

placement date.

11

The National Survey of Child and

Adolescent Well-Being (NSCAW) has

found that “placement stability over the

first eighteen months was significantly

related to all permanency outcomes…”

(Rubin, et al, 2007)

12

In NSCAW, “regardless of a child’s

baseline risk for instability in this study,

those children who failed to achieve

placement stability were estimated to have

a 36% to 63% increased risk of behavioral

problems compared with children who

achieved any stability in foster care.”

(Rubin, et al, 2007)

13

Ryan & Testa (2005) found that male youth with 3

placements were 1.54 times more likely to be found

delinquent in the Illinois Juvenile Justice System than

male youth with 1 placement; male youth with 4

placements were 2.13 times more likely to be found

delinquent than youth with 1 placement.

The CPS substantiation history of children/youth was

also related to delinquency (the greater the number of

substantiated CPS reports the greater the odds of

delinquency). Youth placed out of the home were 1.89

times more likely to be engaged in delinquent acts than

youth remaining in the home.

14

Ryan & Testa comment that “the home environment for

children removed from parental custody is

unquestionably more deleterious compared to maltreated

children whose environment is deemed safe enough for

them to remain at home.”

However, they add, “removing children from these high-

risk environments should decrease the risk of

delinquency. But our findings are that children in

placement are more likely to be delinquent.”

Ryan & Testa assert that placement instability is a major

reason why out-of-home care often fails to have a

therapeutic effect for male youth.

15

The NSCAW found that adolescent

delinquent behavior for youth in out-of-home

care was fairly stable over the first 18

months of placement.

16

Lawrance, Carlson, & Egeland (2006) compared 46 children,

0-9 at entry into care, to 46 maltreated children who remained

at home in a longitudinal study. Developmental outcomes for

these children were compared to 97 non-maltreated children.

Children who had been in foster care had more behavior

problems immediately after exit from care than maltreated

children who had not been placed out of the home.

Adolescent outcomes did not differ for the placed vs. non-

placed maltreated children. Both groups increased in

behavior problems as children became older.

Children placed in kin foster homes had less internalizing

problems at exit from care than children placed in non-kin

homes.

17

Rubin, et al’s (2007) analysis of the National Survey of

Child and Adolescent Well-Being (NSCAW) found that

the strongest predictor of a child’s behavioral

adjustment 18 months after entering care was the

child’s level of behavioral problems at entry into care.

Younger, healthier children with few behavior

problems at entry into care had the best behavioral

outcomes.

Most children with poor CBCL scores at baseline had

abnormal scores 18 months later, even when these

children had stable placements.

18

The NSCAW indicates that in the aggregate

foster care does not markedly improve or

harm children’s functioning for most

behaviorally troubled children.

19

However, aggregate trends for children in care mask

considerable variability in children’s developmental

outcomes. Three factors which mediate these

differences are:

Children’s behavior problems at entry into care,

Children’s placement histories, and

The quality of children’s relationship with substitute

caregivers which are, in turn, affected by caregiver

characteristics such as emotional warmth, acceptance,

skills in managing children’s behavior, and commitment to

the child.

(Rubin et al, 2007; Shlonsky & Berrick, 2001)

20

The evidence continues to mount that exposure to chronic

maltreatment has devastating effects on children’s

development.

In his recently published (2008) study of 347 foster children

4-9 years of age in New South Wales, Australia, Tarren-

Sweeney found that length of exposure to chronic

maltreatment prior to entry into care was the major factor

influencing children’s mental health status.

Tarren-Sweeney asserts that “longer time in care was

protective” (of children’s development), even though almost

20% of the foster children had been abused or neglected in

care.

21

Caregiver Report of Severe Violence

Conflict Tactics Scale Parent to Child version Severe violence sub-scale

hit child with fist or kicked him or her grabbed child around neck and choked him or her beat child up burned or scalded child hit child with a hard object on some other part of the

body besides bottom threw or knocked child down

Limited to children who remained in home following the investigation for maltreatment

(Barth, 2005)

22

65 1

88%

None Improved

Worsened Continued

47 3

86%

None Improved

Worsened Continued

Infants/Toddlers (0-2) Preschoolers (3-5)

(Barth, 2005)

Caregiver Report of Severe Violence

23

Caregiver Report of Severe Violence (2)

104 2

85%

None Improved

Worsened Continued

12

6 5

77%

None Improved

Worsened Continued

Middle Childhood (6-10) Adolescents (11+)

Among children older than 6, a significantly higher proportion had a decreased incidence of severe violence at 18 month than an increased incidence (6-10, p < .01; 11+, p < .05)

(Barth, 2005)

24

Probability of Experiencing Severe Violence

.06.07

.09

.08

.12

.08

0

0.02

0.04

0.06

0.08

0.1

0.12

3 6 10

Baseline

18 months

Age in years*

Violence increases in the lives of the youngest children, then begins to decrease in middle childhood

(Barth, 2005)

25

Caregiver Report of Severe Violence and Official Re-report of Maltreatment for In-home Children

Proportion of all caregivers reporting severe violence at

18 months

% (SE)

Proportion of caregivers reporting severe violence with an official re-report by

18 months % (SE)

0-2 (n=1006) 4.9 (1.3) 8.7 (7.6)

3-5 (n=497) 10.5 (2.9) 25.4 (11.4)

6-10 (n=790) 5.6 (1.1) 39.4 (9.6)

11+ (n=601) 10.2 (2.4) 31.1 (10.6)

Total (n=935) 7.6 (1.1) 28.9 (5.0)All analyses are on weighted data, Ns are unweighted.

• Among caregivers of infants and toddlers who reported using severe violence at 18 months, less than 9% had an official re-report of child maltreatment.

• Overall, of those children with caregiver reported severe violence, 29% had an official re-report.

(Barth, 2005)

26

Conclusions: Re-Report

Although the majority of re-reports are not substantiated, about one in five children has at least one re-report over the 18 months

Children in out-of-home care still have some risk of recurrent maltreatment Possible explanations for maltreatment include:

occurred prior to child entering foster care

occurred during visit with biological family

child on child maltreatment in foster or group home

(Barth, 2005)

27

Conclusions: Re-Report

Receipt of parenting services associated with increased likelihood or re-report Possible explanations include:

Families with greater needs selected into services

Agency surveillance

Services do not adequately family needs

(Barth, 2005)

28

Caregiver Report of Violent Parenting Tactics

Many caregivers (8%) report using severe violence toward their child following child welfare involvement

A large proportion of severe violence remains unreported. This is especially true for infants and toddlers.

Violence between intimate partners often leads to an increase in the amount of severe violence children experience

(Barth, 2005)

29

In addition, there are some studies which

indicate that foster children make better

progress on standard developmental

measures than reunified children.

30(Bellamy, 2008)

31

Bellamy’s analysis (2008) of NSCAW data

for 604 children in foster care for longer

than 8 months found a small overall decline

in CBCL scores while reunified children had

a fourfold increase in internalizing behavior

problems at 18 month follow-up.

32

Bellamy found that reunification outcomes for

children were mediated by caregivers’ mental

health and overall family stress, rather than by

reunification per se.

Bellamy also found that “continued long-term

foster care does not inherently worsen this

high-risk group’s behavioral health over time."

33

Taussig, Clyman, & Landsverk’s (2001) study of

149 ethnically diverse children 7-12 years of age in

foster care for at least 5 months in San Diego

found that “youth who reunify with their biological

families after placement in foster care have more

behavioral and emotional health problems than

youth who do not reunify.”

“These findings were consistent across the range

of outcomes examined: Engagement in risk

behaviors, life course outcomes, and current

emotional and behavioral symptomatology.”

34

The non-reunified youth in Taussig, et al’s

study had experienced an average of 8

placements after 6 years in care.

These researchers could locate only 62% of

reunified youth for the follow-up interview.

35

20-30% of children reunified with birth parents

re-enter out-of-home care within 3-5 years.

For many foster children, placement instability

does not stop with return to birth parents.

36

One possible interpretation of NSCAW findings

regarding out-of-home care is that foster care for

behaviorally-troubled children is neither especially

therapeutic nor harmful, unless children have highly

unstable placement histories.

However, the single most distressing NSCAW

findings regarding out-of-home care concern infants

and toddlers.

37

Infants did worse on developmental measures

after 18 months in care.

National Survey of Childand Adolescent Well-Being (NSCAW)

Bayley Infant Neurodevelopmental Screener (BINS)

Vineland Adaptive Behavior Scales (VABS)

Battelle Developmental Inventory (BDI)

Preschool Language Scale (PLS-3)

38

Developmental Measures in NSCAW

Bayley Infant Neurodevelopmental Screener (BINS)

Vineland Adaptive Behavior Scales (VABS)

Battelle Developmental Inventory (BDI)Preschool Language Scale (PLS-3)

39

Infants (0-3):Overall Change Over 18 Months

-5.73

-2.26

-9

0.5

-10 -8 -6 -4 -2 0 2

PLS-3

BDI

VABS

BINS

Mea

sure

Change in points

Average Score at 18-Months:

6.1

89.6

42.2

88.1

(Barth, 2005)

40

Infants (0-3):Age as a Significant Predictor

-9.78

-5.42

-15.58

-1.66

-4.69

-1.99

-7.61

-0.08

0.51

1.48

0.87

2.25

-20 -15 -10 -5 0 5

PLS-3

BDI

VABS

BINS

Mea

sure

Change in points

Youngest 50th percentile Oldest

Younger infants are much more likely to show greater deterioration

(Barth, 2005)

41

Summary: Age 0-2

No significant measured improvements in development for infants

In general, infants < 2 years decline in all measures, those 25-35 months improve

Children with lower HOME-SF scores see greater declines in three of the four measures

Children in nonurban PSUs see higher risk for developmental delay and neurological impairment and worsening language skills

Males decline in cognitive development and social skills

(Barth, 2005)

42

Summary: Age 3-5

Slight decline in social skills; improvement in language skills; stable level of problem behavior

Age in months is a significant predictor of change, but not in a consistent direction

Prior CWS history is a predictor of change for both social and language skills Could be that they receive greater level of intervention,

this time Could be that prior involvement already raised the level

of their care or treatment(Barth, 2005)

43

Summary: Age 6-10

Only age group that showed improvements, although slight, in all developmental measures examined

Only age group where age is not a significant predictor of rate of change for any domain

Maltreatment type is the only significant predictor across more than one domain, yet with varied results

(Barth, 2005)

44

• Adolescents deteriorated while in foster care

on standard measures of well being.

National Survey of Childand Adolescent Well-Being (NSCAW)

45

Implications

Children who became involved with child welfare services do not show marked gains in development during the first 18-months The youngest children show declines on

developmental measures Out-of-home care does not appear to offer

protection leading to improvement in developmental status over 18 months as might be expected Yet, among the older children, those with prior

CWS involvement did better(Barth, 2005)

46

Implications

CWS may be focusing on the more explicit goals of safety and permanency than on well-being, which appears to be beyond its current scope Revisions to CAPTA that require referrals of

substantiated infant cases to early intervention seem very timely and need rapid implementation

Specialized infant units may also be valuable Reductions in infant placements my help

(Barth, 2005)

47

The growth in kinship care has been described

by one scholar as the most significant change in

foster care services over the past two decades.

In Washington State, the kinship care rate has

increased from around 26% to 40% of children in

out-of-home care.

48

Kinship care is more stable than

foster care.

49

However, an analysis of NSCAW data (n=567) by

Barth, Guo, Green, and McCrae (2007) found that

children in non-kin foster care were more

behaviorally troubled at baseline than children

placed with relatives. These authors state that

“differences between children in kinship and non-

kinship care… may simply reflect these pre-

existing differences…”

50

In this same NSCAW analysis, children in kinship

care improved more on the CBCL after 18

months in care than children in non-kin care; but

on other developmental measures (e.g.,

Vineland, Social Skills Rating System), there

were no significant differences in improvement /

lack of improvement at 18 months after entry into

care.

51

One of the most concerning findings in this study is that

“about one-fifth of the children were rated as

experiencing both low responsiveness and high

punitiveness at both baseline an at 18 months,” a

statistic that did not differ for kin and non-kin caregivers.

“Low responsiveness” and “high punitiveness” is

another way of describing harsh emotionally

unresponsive parenting.

52

This study also found that one-fifth of foster

parents (kin and non-kin) were poor, and that

only 42% of non-kin foster parents had more

than a high school degree.

“Any general notion that foster parents are

predominantly middle-class is untrue,” these

authors state.

53

Acute and chronic placement shortages are

having a large negative effect on the quality of

foster care in Washington State and nationally.

54

Foster care systems experiencing acute and chronic shortages of homes cannot:

Match children’s needs to foster family strengths and capacities

Keep siblings together, especially sibling groups of larger than 2 children

Place children in their own neighborhoods / communities

Maintain high standards of care

55

Foster home recruitment initiatives over the past 10 years have not been effective despite a large investment of resources; and, as a result, the Children’s Administration has placed an increased emphasis on kinship care.

56

New strategies must be found to recruit and retain foster homes, or the number of children entering out-of-home care must be greatly reduced.

57

Possible strategies:

Neighborhood- / community-based recruitment campaigns

Professional foster care Better support / a larger percentage of the foster

care system run by private agencies

58

It is also useful to have some humility about our collective understanding of the needs of children.

What do these items have in common?

Indenture Almshouses Orphanages Orphan Trains / Foster care Mother’s Pensions Therapeutic Foster Care Kinship Care / Family Group Conferencing Juvenile Institutions Residential Care Wrap Around / Community Placement

All of the items on this list were child welfare reforms at one point.

59

Nevertheless, the need for non-kin foster care

is not likely to greatly diminish without dramatic

reductions in the child poverty rate and/or major

improvements in child welfare in-home services

for parents with co-occurring substance abuse

and mental health disorders.

60

Barth and his colleagues have written that “a

vision for excellence in foster care is needed.”

These experts recommend increasing financial

support for foster parents, “linking every foster

parent to a resource center” or resource

person, and providing “consistent, powerful,

supportive in-home training.”

61

It is difficult to understand how foster care can

become a therapeutic system for behaviorally-

troubled children without developing a cadre of

professional foster parents and implementing

evidence-based practice models.

62

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nonkinship foster care: Informing the new debate. In R. Haskins, Wulczyn,

F., & Webb, M. B. (Eds.), Child protection: Using research to improve policy

and practice (pp. 187-206). Washington, D.C.: Brookings Institution Press.

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